We sought to evaluate sociodemographic disparities in insurance coverage among nonelderly adults with a common cancer after Affordable Care Act (ACA) implementation.
In total, 109,182 patients aged ...18 to 64 years diagnosed with a common cancer (lung, breast, or prostate cancer) were identified from 2010 to 2014. Multivariable logistic regressions analyzed associations between ACA implementation and uninsured rates on the basis of state approach to Medicaid expansion, stratified by race (black, white), and income (stratified at 138% Federal Poverty Line).
Uninsured rates declined after ACA implementation, with the greatest rate reductions associated with traditional Medicaid expansion (Pinteraction <0.001). Racial disparities in insurance coverage were eliminated with traditional Medicaid expansion where the uninsured rate went from 10.0% to 0.95% among black patients (adjusted odds ratio AORpre-aca 1.52 to AORpost-aca 0.47) but persisted with other state approaches (AORpre-aca 1.15 to AORpost-aca 1.12) (Pinteraction =0.002). Furthermore, socioeconomic coverage gaps were eliminated with traditional Medicaid expansion, where the uninsured rate went from 8.4% to 1.4% among low-income (≤138% Federal Poverty Line) patients, but not with other state approaches (Pinteraction <0.001).
Traditional Medicaid expansion was associated with the elimination of racial and socioeconomic insurance coverage gaps. These results highlight the potential benefits and challenges of the ACA and its provisions, and could instruct ongoing policy.
Objective
To determine whether patients with Gleason score 5 + 3 = 8 prostate cancer have outcomes more similar to other patients with Gleason score 8 disease or to patients with Gleason score 9 ...disease.
Patients and Methods
The Surveillance, Epidemiology and End Results (SEER) database was used to study 40 533 men diagnosed with N0M0 Gleason score 8 or 9 prostate cancer from 2004 to 2011. Using Gleason score 4 + 4 = 8 as the referent, Fine and Gray competing risks regression analyses modelled the association between Gleason score and prostate cancer‐specific mortality (PCSM).
Results
The 5‐year PCSM rates for patients with Gleason score 4 + 4 = 8, 3 + 5 = 8, 5 + 3 = 8, and 9 disease were 6.3%, 6.6%, 13.5%, and 13.9%, respectively (P < 0.001). Patients with Gleason score 5 + 3 = 8 or 9 disease had up to a two‐fold increased risk of PCSM (adjusted hazard ratio AHR 1.89, 95% confidence interval CI 1.50–2.38, P < 0.001; and AHR 2.17, 95% CI 1.99–2.36, P < 0.001, respectively) compared with the referent group of patients (Gleason score 4 + 4 = 8). There was no difference in PCSM between patients with Gleason score 5 + 3 = 8 vs 9 disease (P = 0.25).
Conclusions
Gleason score 8 disease represents a heterogeneous entity with PCSM outcomes distinguishable by the primary Gleason pattern. The PCSM of Gleason score 3 + 5 = 8 and Gleason 4 + 4 = 8 disease are similar, but patients with Gleason score 5 + 3 = 8 have a risk of PCSM that is twice as high as other patients with Gleason score 8 disease and should be considered to have a similar poor prognosis as patients with Gleason score 9 disease. Such patients should be allowed onto trials seeking the highest‐risk patients in which to test novel aggressive treatment strategies.
Although the association between higher hospital volume and improved outcomes has been well-documented in surgery, there is little data about whether this effect exists for radiation-treated ...patients. We investigated whether treatment at a radiation facility that treats a high volume of prostate cancer patients is associated with improved survival for men with high-risk prostate cancer.
We used the National Cancer Database (NCDB) to identity patients diagnosed with prostate cancer from 2004 to 2006. The radiation case volume (RCV) of each hospital was based on its number of radiation-treated prostate cancer patients. We used propensity-score based analysis to compare the overall survival (OS) of high-risk prostate cancer patients in high versus low RCV hospitals. Primary endpoint is overall survival. Covariates adjusted for were tumor characteristics, sociodemographic factors, radiation type, and use of androgen deprivation therapy (ADT).
A total of 19,565 radiation-treated high-risk patients were identified. Median follow-up was 81.0 months (range: 1-108 months). When RCV was coded as a continuous variable, each increment of 100 radiation-managed patients was associated with improved OS (adjusted hazard ratio AHR: 0.97; 95% confidence interval CI: 0.95-0.98; P<.0001) after adjusting for known confounders. For illustrative purposes, when RCV was dichotomized at the 80th percentile (43 patients/year), high RCV was associated with improved OS (7-year overall survival 76% vs 74%, log-rank test P=.0005; AHR: 0.91, 95% CI: 0.86-0.96, P=.0005). This association remained significant when RCV was dichotomized at 75th (37 patients/year), 90th (60 patients/year), and 95th (84 patients/year) percentiles but not the 50th (19 patients/year).
Our results suggest that treatment at centers with higher prostate cancer radiation case volume is associated with improved OS for radiation-treated men with high-risk prostate cancer.
Background
There is substantial variation in head and neck cancer (HNC) mortality and competing mortality among patients with HNC. In this study, the authors characterize the causes and risks of ...short‐term mortality among patients with oropharynx cancer (OPC) and how these risks differ by human papillomavirus (HPV) status.
Methods
A custom Surveillance, Epidemiology, and End Results (SEER) data set with HPV status was used to identify 4930 patients with OPC who were diagnosed with nonmetastatic (M0) disease from 2013 to 2014, including 3560 (72.2%) HPV‐positive patients and 1370 HPV‐negative patients. Causes of death and cumulative incidence estimates for HNC‐specific mortality, competing mortality, second‐cancer mortality, and noncancer mortality were analyzed by HPV status. Risk factors for mortality events were determined using multivariable competing risk regression models.
Results
Compared with HPV‐negative patients, HPV‐positive patients had a lower risk of 2‐year cumulative incidence of all‐cause mortality (10.4% vs 33.3%; P < .0001) and a lower risk of both HNC‐specific mortality (4.8% vs 16.2%; P < .0001) and competing‐cause mortality (5.6% vs 16.8%; P < .0001). Second‐cancer mortality was the most common cause of non‐HNC mortality among HPV‐negative patients. Both second‐cancer mortality and noncancer mortality were significantly higher among patients who had HPV‐negative OPC (10.8% and 6.1%, respectively) compared with those who had HPV‐positive OPC (2.4% and 3.2%, respectively; both P < .0001). The median follow‐up was 11 months (range 1‐23 months) in this cohort with known HPV‐status.
Conclusions
Patients with HPV‐positive and HPV‐negative OPC have significantly different rates of both HNC mortality and competing mortality. HPV‐negative patients are at substantial risk of competing mortality, even within 2 years of cancer diagnosis. These differences can inform power calculations for clinical trials and patient management in the acute and survivorship settings.
Patients with human papillomavirus (HPV)‐positive and HPV‐negative oropharyngeal cancer have significantly different risks of both head and neck cancer–specific and competing mortality, and HPV‐negative patients are at a substantial risk of short‐term competing risks of mortality after diagnosis and treatment of head and neck cancer. These differences can inform power calculations for clinical trials and patient management in the acute and survivorship settings.
Evidence supports the value of shorter, similarly efficacious, and potentially more cost-effective hypofractionated radiation therapy (RT) regimens in many clinical scenarios for breast cancer (BC) ...and prostate cancer (PC). However, practice patterns vary considerably. We used the most recent Centers for Medicare and Medicaid Services data to assess trends in RT cost and practice patterns among episodes of BC and PC.
We performed a retrospective cohort analysis of all external beam RT episodes for BC and PC from 2015 to 2019 to assess predictors of short-course RT (SCRT) use and calculated spending differences. Multivariable logistic regression defined adjusted odds ratios of receipt of SCRT over longer-course RT (LCRT) by treatment modality, age, year of diagnosis, type of practice, and the interaction between year and treatment setting. Medicare spending was evaluated using multivariable linear regression controlling for duration of RT regimen (SCRT vs LCRT) in addition to the above covariables.
Of 143,729 BC episodes and 114,214 PC episodes, 63,623 (44.27%) and 25,955 (22.72%) were SCRT regimens, respectively. Median total spending for SCRT regimens among BC episodes was $9418 (interquartile range IQR, $7966-$10,983) versus $13,602 (IQR, $11,814-$15,499) for LCRT. Among PC episodes, median total spending was $6924 (IQR, $4,509-$12,905) for stereotactic body RT, $18,768 (IQR, $15,421-$20,740) for moderate hypofractionation, and $27,319 (IQR, $25,446-$29,421) for LCRT. On logistic regression, receipt of SCRT was associated with older age among both BC and PC episodes as well as treatment at hospital-affiliated over freestanding sites (P < .001 for all).
In this evaluation of BC and PC RT episodes from 2015 to 2019, we found that shorter-course RT resulted in lower costs than longer-course RT. SCRT was also more common in hospital-affiliated sites. Future research focusing on potential payment incentives encouraging SCRT when clinically appropriate in the 2 most common cancers treated with RT will be valuable as the field continues to prospectively evaluate cost-effective hypofractionation in other disease sites.
Alcohol use is an established risk factor for several malignancies and is associated with adverse oncologic outcomes among individuals diagnosed with cancer. The prevalence and patterns of alcohol ...use among cancer survivors are poorly described.
We used the National Health Interview Survey from 2000 to 2017 to examine alcohol drinking prevalence and patterns among adults reporting a cancer diagnosis. Multivariable logistic regression was used to define the association between demographic and socioeconomic variables and odds of self-reporting as a current drinker, exceeding moderate drinking limits, and engaging in binge drinking. The association between specific cancer type and odds of drinking were assessed.
Among 34,080 survey participants with a known cancer diagnosis, 56.5% self-reported as current drinkers, including 34.9% who exceeded moderate drinking limits and 21.0% who engaged in binge drinking. Younger age, smoking history, and more recent survey period were associated with higher odds of current, exceeding moderate, and binge drinking (P<.001 for all, except P=.008 for excess drinking). Similar associations persisted when the cohort was limited to 20,828 cancer survivors diagnosed ≥5 years before survey administration. Diagnoses of melanoma and cervical, head and neck, and testicular cancers were associated with higher odds of binge drinking (P<.05 for all) compared with other cancer diagnoses.
Most cancer survivors self-report as current alcohol drinkers, including a subset who seem to engage in excessive drinking behaviors. Given that alcohol intake has implications for cancer prevention and is a potentially modifiable risk factor for cancer-specific outcomes, the high prevalence of alcohol use among cancer survivors highlights the need for public health strategies aimed at the reduction of alcohol consumption.
Resistance to cancer treatment remains a major clinical hurdle. Here, we demonstrate that the CoREST complex is a key determinant of endocrine resistance and ER
breast cancer plasticity. In ...endocrine-sensitive cells, CoREST is recruited to regulatory regions co-bound to ERα and FOXA1 to regulate the estrogen pathway. In contrast, during temporal reprogramming towards a resistant state, CoREST is recruited to AP-1 sites. In reprogrammed cells, CoREST favors chromatin opening, cJUN binding to chromatin, and gene activation by controlling SWI/SNF recruitment independently of the demethylase activity of the CoREST subunit LSD1. Genetic and pharmacological CoREST inhibition reduces tumorigenesis and metastasis of endocrine-sensitive and endocrine-resistant xenograft models. Consistently, CoREST controls a gene signature involved in invasiveness in clinical breast tumors resistant to endocrine therapies. Our studies reveal CoREST functions that are co-opted to drive cellular plasticity and resistance to endocrine therapies and tumorigenesis, thus establishing CoREST as a potential therapeutic target for the treatment of advanced breast cancer.
•The kinetics of PSA decline differed between SBRT, HDR-BT, and LDR-BT.•Lower nPSA, longer decay to nPSA, and greater achievement of PSA <0.2 ng/mL was seen after LDR-BT.•Though PSA kinetics and ...degrees of prostatic ablation differed, biochemical control was similar.•Continued PSA decline >4 years post-treatment was predictive of durable biochemical control.
Stereotactic body radiation therapy (SBRT), low dose rate brachytherapy (LDR-BT) and high dose rate brachytherapy (HDR-BT) are ablative-intent radiotherapy options for prostate cancer (PCa). These vary considerably in dose delivery, which may impact post-treatment prostate-specific antigen (PSA) patterns and biochemical control. We compared PSA kinetics between SBRT, HDR-BT, and LDR-BT, and assessed their relationships to biochemical recurrence-free survival (BCRFS).
Retrospective PSA data were analyzed for 3502 men with low-risk (n = 2223; 63.5%), favorable intermediate-risk (n = 869; 24.8%), and unfavorable intermediate-risk (n = 410; 11.7%) PCa treated with SBRT (n = 1716; 49.0%), HDR-BT (n = 512; 14.6%), or LDR-BT (n = 1274; 36.4%) without upfront androgen deprivation therapy at 10 institutions from 1990 to 2017. We compared nadir PSA (nPSA), time to nPSA, achievement of nPSA <0.2 ng/mL and <0.5 ng/mL, rates of nPSA <0.4 ng/mL at 4 years, and BCRFS.
Median follow-up was 72 months. Median nPSA and nPSA <0.2 ng/mL were stratified by risk group (interaction p ≤ 0.001). Median nPSA and time to nPSA were 0.2 ng/mL at 44 months after SBRT, 0.1–0.2 ng/mL at 37 months after HDR-BT, and 0.01–0.2 ng/mL at 51 months after LDR-BT (mean log nPSA p ≤ 0.009 for LDR-BT vs. SBRT or HDR-BT for low/favorable intermediate-risk). There were no differences in nPSA <0.4 ng/mL at 4 years (p ≥ 0.51). BCRFS was similar for all three modalities (p ≥ 0.27). Continued PSA decay beyond 4 years was predictive of durable biochemical control.
LDR-BT led to lower nPSAs with longer continued decay compared to SBRT and HDR-BT, but no differences in BCRFS.
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